Like a football free agent, Dr. David Hojnacki fields enticing offers every day to leave Buffalo.
He could settle anywhere he wants. Dallas dangled $400,000 a year plus perks, more than double what he's likely to make here as a specialist just starting his career.
Others have offered packages that are nearly as good or better.
Hojnacki grew up in Niagara Falls, so he decided to remain close to home.
But many physicians can't pass up the lure of cities with higher salaries, newer facilities and sunnier weather.
The Buffalo Niagara region's disadvantages at keeping the doctors it trains and recruiting the physicians it needs is leading to shortages in some specialties and concern about the future.
The demand for medical talent is expected to turn even fierc er with an impending shortage of doctors in the nation.
"I'm staying, but people are always telling me, 'You're young. If you're smart, you should leave,' " said Hojnacki, who will soon complete his residency in neurology and work at Jacobs Neurological Institute of Kaleida Health.
Buffalo Niagara was one of only two regions in the state that experienced a loss of doctors between 2000 and 2004, according to a recent report by the University at Albany's Center for Health Workforce Studies.
Overall, the number of doctors declined by 10 percent, although there were larger percentage decreases in general surgery, psychiatry, obstetrics-gynecology and internal medicine specialists.
>Problem is urgent
Other surveys have come to similar conclusions. Buffalo's physician community is thinning and graying.
Kaleida Health, the region's largest hospital system, estimates the community will need as many as 450 new physicians over the next seven years to replace retirees and others who leave, including pediatricians, radiologists and cardiologists.
The problem is urgent enough that the Catholic Health System is hiring a full-time recruiter as part of a broader strategy to attract and keep doctors.
But no one is sure where the replacements will come from.
"We've got a situation where about the only people we can recruit come from Buffalo and didn't leave, left and decided to return or married someone from Buffalo," said Dr. Robert Gatewood, president of Buffalo Cardiology and Pulmonary Associates.
The decline in general surgeons is especially acute and indicative of the problem.
Today, there are eight general surgeons for every 100,000 people in the region, a decrease of 21 percent between 2000 and 2004, according to the Center for Health Workforce Studies. Its report listed the percentage decline in Niagara County alone at 45 percent.
In surveys of the medical work force, the Catholic Health System determined that Erie County will need around 93 general surgeons by 2008, an increase of about 32 to the current group, whose average age is now close to 60. That will be an enormous challenge.
"We haven't recruited 32 surgeons in the last 10 years," said Dr. Brian D'Arcy, senior vice president for medical affairs.
To make matters worse, general surgeons are retiring or reducing their hours at a greater rate than other physicians.
The shortage is bad enough that some hospitals in the region often can't do common surgical cases for lack of a surgeon and routinely transfer patients to larger medical centers.
"There's concern about who's going to be around at 2 a.m. to do an appendectomy," said Dr. James Hassett, program director for general surgical training at the University at Buffalo School of Medicine and Biomedical Sciences.
To Hassett, part of the problem is that two-thirds of the doctors-in-training in Buffalo go elsewhere to work. It's an easy choice for new doctors, many of whom start careers with medical school debts well over $100,000.
"We train them but wind up exporting most of them," he said.
It's not just about following the money. Physicians today want up-to-date equipment to do their jobs.
Young neurologists weaned on the Internet expect hospitals to have digital systems for displaying and transmitting X-rays, MRIs, laboratory results and medical records that can be viewed from a home computer or a screen anywhere, Hojnacki said.
>New tools needed
Major hospitals in Buffalo have embarked on multimillion-dollar projects in recent years to install computer systems to keep records, schedule services, process bills, store images and match drugs to patients. But facilities here have lagged behind other areas of the country and still do in certain medical technologies.
"Doctors coming out of training want the tools they have trained with," D'Arcy said. "If you don't have the tools, they don't want to even talk to you."
Lifestyle changes also have contributed to a tightening of the job market.
Newer generations of physicians want more regular hours. And with demand so high for their services, they can generally locate in popular urban areas and not necessarily where they are most needed.
One other dramatic shift in the field has been the rise in the percentage of women physicians, from 9 percent in 1975 to 25 percent in 2005. More are on the way.
"You can't change reproductive biology," said Dr. Stephanie Pincus, professor and chairwoman emeritus of the UB dermatology department and an expert on women in the medical work force.
Because medical school and residency afterward coincide with a woman's peak child-bearing years, Pincus said, the profession must adjust to allow part-time doctor training and more part-time doctoring.
"Women will drop out if the system doesn't accommodate them," she said.
>Glut never happened
Recruitment challenges here are playing out as the United States faces a physician shortage.
For several decades, the American Medical Association and other medical groups feared the nation was headed toward an oversupply of physicians and helped put in place policies to limit their number.
The glut never happened. Instead, experts now believe the country will need many more doctors in the future and had better do something about it now, because it takes about 10 years to produce a physician.
"Few people realize how long it takes to change the supply of doctors. We can't wait around until there is a shortage in a decade or so from now," said Edward Salsberg, director of the Center for Workforce Studies at the American Association of Medical Colleges.
New recommendations would produce 30,000 new doctors by 2020, increasing the total physician work force to slightly more than 1 million. But the problem is potentially large enough that officials are now considering a 30 percent increase in medical school enrollment, Salsberg said.
Not everyone agrees.
Critics argue that there are enough doctors but that they are inefficiently used and poorly distributed. They worry that having more doctors will drive up health costs. They also wonder how much people are willing to pay in health insurance and taxes to support a health system that already accounts for 15 percent of the economy.
"There is a lot of slack in the physician work force. It's what doctors do, not how many are doing it, that relates to good care," said Dr. David Goodman, a Dartmouth College researcher.
Efforts, he said, should focus on emulating hospitals similar to the well-regarded Mayo Clinic, which uses fewer doctors at lower cost to manage patients with chronic illnesses, yet provides care as good as or better than hospitals that involve more physicians in cases.